Head moulding: Controversial practice that refuses to die

TOLUWANI ENIOLA writes about the practice of moulding the heads of newborns in Nigeria and the dangers

Two years ago, Mrs. Ronke Adedeji’s joy knew no bounds when she gave birth to her first child.

The newborn was greeted with elation from family members and friends. But unlike other new mums, her mind was filled with worry about her baby’s head shape.

Though relishing the joys of motherhood and the task of parenting, her most concern was her baby’s oblong head.

“My mother confirmed my worry and told me a little moulding of the baby’s head would restore it to normal. She told me she did a similar thing for me when I was a child,” said Adedeji who was delivered of her baby by traditional birth attendants.

Although educated, Adedeji preferred to be delivered of her baby by TBAs because she felt they offer better maternal care and cheaper services.

She gleefully narrated her story, “When I got home after giving birth, my mum bathed the baby. She heated water, not to the boiling point and dipped a small towel inside the water. She squeezed the water out and gently massaged the baby’s head. She later used her hands to pattern the baby’s head roundly, as if moulding clay.

“I was scared when the baby yelled a few times but she assured me that there was no cause for concern. She told me that if the water was too hot, it would burn the child’s scalp. Sometimes, I felt like telling her to stop but I soon got used to it. This was done for three months until Pelumi’s head became normal.”

Adedeji excitedly told SUNDAY PUNCH she would do a similar thing if her second child’s head is irregular having diligently observed the process from her mother.

She said, “I think it is a cultural practice among the Yoruba to remould a child’s head a few days after birth. We believe that if the baby’s head is big or irregular, there is a need to reduce the shape. It will make the child beautiful.

“I have never seen a child that didn’t go through this. Many years ago, most ladies had moderate heads, but these days, it is common to see ladies with very big heads. The truth is that they didn’t mould their heads at birth because they were delivered of their babies in formal hospitals. Do you think they like the shape of their heads?”

Like Adedeji, Mrs. Esther Akinraiye, a mother of two, did not feel comfortable with the shape of her second child’s head when she gave birth. She had also been taught by her husband’s mother that shapening her baby’s head after delivery was the best way to curtail a protrusion at the back of her child’s head.

What Akinraiye called a protrusion at the back of her baby’s head is generally referred to as “ogo” in Yoruba.

Ogo and oriloko are used derogatorily to describe children with such heads, especially in South-West Nigeria.

These children are the butt of jokes in schools among their peers and Akinraiye did not want such nasty experience for her child.

“When I delivered my first child, my husband’s mother visited, as usual, to lend a hand in caring for the baby. We left the hospital the second day I gave birth. Using warm water, she massaged my baby’s head till the ogo reduced. When I gave birth to my second child, I did it too for him like a month and the head became normal,” she added.

Although she gave birth at a modern hospital, Akinraiye explained that nobody had ever told her such practice was wrong. She stated, “We were not told at the hospital, maybe because we never asked because it’s the usual practice. I am hearing it for the first time that it could cause damage to the child’s brain.”

The case of a housewife and mother of three identified only as Mrs. Olujimi is similar. Olujimi stated that she moulded her children’s heads at home “because it’s not done in the hospital.”

She said, “I did it for my three children. It is done because the baby’s head is very soft and easy to shape.”

Asked if her husband objected to the practice, Olujimi added, “He didn’t say anything but no man will like to see his child’s head to look abnormal. How long the head of the child will determine the days and time needed to finalise the moulding.”

The practice of moulding a child’s head as exemplified by these Nigerian mothers may sound awkward but it is quite common.

SUNDAY PUNCH learnt that although the ritual had been outlawed in standard hospitals, it has continued to be the norm in informal health centres.

Head moulding dangerous —Expert

According to a paediatrician, Dr. Aziagba, while Adedeji and Akinraiye’s children did not develop any complications, the same cannot be said of other children who went through this ritual in order to “look normal or conform to the shape that their parents desire.”

Aziagba is one of those championing the abolition of this practice. Speaking with our correspondent, he lamented that some children had been incapacitated as a result of head moulding.

The doctor said that mothers express worry about the shapes of the heads of their babies at birth because of ignorance.

He noted that babies could develop misshapen heads if the birth canals of their mothers are too tight.

Explaining why babies have irregular heads at birth, Aziagba said, “A baby’s pieces of bones are not fused. They are held together in loose form so that the baby can navigate the birth canal easily. The canal is the passageway from the womb through the cervix, the vagina, and the vulva through which a foetus passes during birth. As the baby’s head descends into the birth canal, the head of the baby may be elongated, in the process of wriggling through that canal to come out.

“Tight birth canals impose pressure effect and put trauma on the head of that baby. This is why when some children are born, their heads are swollen up here and there. This is normal and such heads take normal shape as the baby grows. Many parents hardly wait but try to manually mould the head. This is where problems come.”

Aziagba further explained the complications likely to arise from head moulding. He said, “When somebody uses his or her hands to mould the head of the baby without minding the fact that babies’ heads are fragile, what they cause is trauma. This trauma can cause bleeding on the scalp; that will not cause much harm to the baby.

“But they might cause bleeding inside the brain if the pressure with which they are moulding the head is too much. That bleeding can cause damage to the brain. When there is such damage, the commonest consequence is what we call cerebral palsy; a child with the condition does not carry his head when others do. He doesn’t crawl. He doesn’t stand when others walk. Aside from this, it can cause permanent brain damage. When such a child is 15 years, for instance, he can be passing urine in his clothes.”

He stressed that pressure on the neck of such babies during the moulding could make their head tilt towards one side, adding, “You think that they are strutting, no. They got that while trying to shape their heads at birth. Such remoulding bent the neck and strained the muscles to the point that they remain stiff in that position.”

There is no data on how many of these children develop complications as a result of head moulding. But Consultant Paediatrician, Prof. Abiodun Lesi, estimated that close to 700,000 Nigerian children suffer from cerebral palsy, one of the major consequences of the practice.

Why head moulding thrives

A midwife at a government hospital in Ogun State, identified only as Mrs. Badejo, said the practice persisted because many deliveries take place outside formal health facilities in Nigeria.

At a recent forum in Abuja, the Association for the Advancement of Family Planning raised the alarm that 90 per cent of women in northern Nigeria give birth to their babies at home.

This claim is further substantiated by the 2013 National Demographic and Health Survey which noted that skilled attendance at birth remains low at 38 per cent and only 36 per cent of births in Nigeria are delivered in a health facility.

Badejo revealed that many pregnant women registered with the TBAs and formal health facilities, adding that when it is delivery time, they go to the TBAs.

According to her, when such mothers deliver at the TBAs, they do not get proper postnatal care and instruction on how to care for the baby.

According to the World Health Organisation, the postnatal period begins from the hour after the delivery of the placenta and continues until six weeks after giving birth.

WHO describes this postnatal care as one of the most important maternal health care services crucial to the health and survival of a mother and her baby.

Experts say the postnatal period provides the right opportunity to deliver interventions to reduce complications and neonatal deaths.

Such early postnatal care visit available in public hospitals enables the mothers to access information and support for crucial things such as proper nutrition for the newborn, exclusive breastfeeding, family planning and best practices on caring for the baby.

It also provides an opportunity for the mothers to ask questions on major concerns such as the shapes of their babies’ heads.

A nurse with a tertiary hospital, who does not want to be named because she is a civil servant, lamented that the TBAs largely neglect this critical period despite receiving training on it.

The nurse, who trained many TBAs, observed that although the TBAs had further added value to maternal care in Nigeria, there is a lack of proper monitoring of their activities to ensure compliance with the standards.

She added, “Pregnant women prefer to patronise TBAs because they charge less money. As long as pregnant women patronise the TBAs, there will still be problems. Some of the TBAs who undergo training comply with the standard but some of them go beyond the training and it is only because of the financial gains.

“I have seen many referrals from such TBAs when the head moulding turns awry. Most of the complications that arose are linked with the brain of the child. Some of them have mental retardation, in varying degrees, depending on how much moulding is done. Some of them are slow at learning, it could even be worse. I have seen a few cases of death.”

Excesses of TBAs

Findings by our correspondent showed that the nurse’s observations were true.

Mrs. Titilayo Esan is used to delivering babies. As a traditional birth attendant in Lagos, she told SUNDAY PUNCH that she had delivered over 100 babies who experienced head moulding.

Esan also argued that the majority of adults who experienced head moulding at birth would have developed brain damage if it was as dangerous as health experts said.

She believes that nurses in standard hospitals do not mould a child’s head because they are not skilled in that aspect.

She said, “I have moulded over 100 babies’ heads which didn’t have any issue or side effects. What I can say is that complications arise because those who did it are not skilled like I am. Those unskilled ones are the ones giving us a bad name.

Esan also tried to shed light on the practice, saying, “There are processes and certain steps to moulding a child’s head. If the head is too long or pressed together or divided in the middle, I will get a cloth, probably an ankara, dip it into hot water to shape the head. I hold the baby’s head from the front, adjust it by using my hand from the back and shift the head from the back.

“The four edges of the head will be moulded perfectly by the hand to get the precise shape preferred by the parent. This is also done in the night, for the first few days.”

Sharing her techniques, another TBA, Mrs. Ibidun revealed another source of concern. Like Esan, she believed it’s right to mould a child’s head.

She said, “I do it (head moulding) for couples whose children have big heads or those with ogo and those with opon ori (protrusion on the forehead).

“If I discover that the ogo is soft and there are some with blood tissues on the head, I usually refer to the hospital. If there is no blood, I use akisa (rag) dipped in warm water to massage the head till it takes shape. If this is not done, the head may be too big for the baby. There are some babies that their heads will be too big for the neck to bear, sometimes; he may find it hard to twist their neck. Remoulding is needed.”

But Dr. Uduak Offiong, a paediatrician described the practice as abhorrent. She advised mothers to stop remoulding their children’s heads, adding that the practice was dangerous.

Offiong has a few pieces of advice for parents who noticed their children have big or irregular heads after birth.

Rather than worry about the shape of their babies’ heads, she advised them to visit formal hospitals or paediatric centres for medical interventions.

She said, “A big head is never a normal thing, so this should be checked by a paediatrician. There are norms for head size by age. Mothers should know that the shape of a baby’s head is genetically determined in normal situations.

“A small head or a big head connotes an abnormality, which requires assessment by a paediatrician. Head moulding is potentially dangerous and its practice is highly discouraged. There are many causes of an enlarged or abnormal head shape, from brain malformations to complications of infections/birth injuries, to conditions that cause a disruption in the development of the skull.”

Offiong added, “Moulding of the skull may lead to brain injury. The skull of a baby is very fragile and the brain is delicately encased. So, excessive pressure can easily damage the brain. If the processes of moulding cause brain injury, then the long-term effects can manifest as neuro-developmental problems such as learning disabilities. The injury may not be evident early so long-term problems may not even be attributed to the process.”

Aziagba stressed that it is normal for a child to develop “ogo” or “opon ori”, noting that living with such shapes is better than brain damage that may arise from head moulding.

He said, “I have seen many children with oxycephaly (children whose top of the skull is pointed or conical) and they are living normal lives. In fact, I use to joke with some of them that if they head a ball with their conical shape, it will go straight into the net.”

Badejo advised federal and state governments to employ more doctors and nurses and equip the hospitals. According to her, doing this will increase patronage at the hospitals.

She said, “People are retiring and they are not hiring. Imagine a general hospital with just eight nurses who run 24-hour shift. The frightening environment does not encourage patronage. How can one nurse man a 30-bed ward? Those are the kinds of things we see in hospitals.

“In rural areas, one nurse will be on duty for 30 days. They call it MAN (morning, afternoon and evening) so, people don’t have enough time to educate the women. Where they need forceps delivery, there is hardly anybody to do it.”

She also advised fathers to develop an interest in caring for their babies. The midwife believes that men are able to assert their authority when their wives feel like moulding their children’s heads.

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